October 14, 2005

Treatment of Adolescent and Child Schizophrenia

Schizophrenia is much less common in children than in adults. Where about 1 in 100 adults suffer from schizophrenia, only about 1/3 of those people (1 in 300) showed symptoms before age 18 and only about 1 in 10,000 children develop the disease before the age of 12. Much less is known about schizophrenia in children and adolescents than in adults. Current thinking suggests that child onset schizophrenia is simply a more severe form of the disease. However, clinical experience in the treatment of youth with major depressive disorder and bipolar disorder, which are more common, has shown that children and adolescents often react differently to pharmacological treatment than do adults. Early detection and treatment may improve outcomes so it is important to know which antipsychotic agents are safe and effective for children. Unfortunately, most pharmaceutical research is conducted on adults; very few controlled studies have been performed on children. This paper by Young and Findling summarizes what is known about the treatment of children and adolescents with schizophrenia.

Child onset schizophrenia is frequently resistant to treatment, especially with typical antipsychotics. Of the 14 typical antipsychotics currently available for use in the U.S. only haloperidol, loxapine (Loxapac®, Wyeth-Ayerst Laboratories, PA. USA), thioridazine (Melleril®, Novartis Pharmaceuticals Corp., Basel, Switzerland), and thiothixene (Navane®, Pfizer Inc., NY, USA) have any data concerning their use on children, and even this data lacks true scientific validity because of the small sample sizes used and the uncontrolled nature of the studies. However, the results of these studies indicate that a substantial portion of young patients (15-45% depending on the drug) show little or no improvement while taking the drug. These studies also showed a high rate of potentially debilitating side effects and, along with additional clinical experience, suggest that your people are at higher risk than adults are. The most common side effects of typical antipsychotics were sedation and extrapyramidal side effect (EPS), which are characterized by motor deficits including loss of postural reflexes, bradykinesia (abnormally slow movement), tremor, rigidity, and involuntary movements. These and other side effects often result in poor adherence to treatment regimens and, in more severe cases, can lead to nonreversible or life threatening conditions.

Atypical antipsychotics work through a different mechanism of action than the typical antipsychotics and are often effective on treatment resistant forms of schizophrenia. The body of research on atypical antipsychotic use in children is similar to that of the typical antipsychotics with most data coming from case reports and small, uncontrolled trials. However, what is known about the use of these drugs is summarized here:
· clozapine (Clozaril®, Novartis Pharmaceuticals Corp.) – Showed significant benefit for both positive and negative symptoms compared to haloperidol, as well as reduced frequency of EPS. However, clozapine is usually reserved for otherwise treatment resistant forms of schizophrenia because of possibly life threatening side effects such as a decrease in white blood cell count, heart disease, and seizures.
· risperidone (Risperdal®, Organon, NJ, USA) – Available information suggests that risperidone is effective in the majority of young patients, with the most common side effects being EPS, sedation, and weight gain.
· olanzapine (Zyprexa®, Eli Lilly & Co., IN. USA) – Data suggests that olanzapine is effective in reducing positive and negative symptoms in most young patients with the most common side effects being sedation and weight gain.
· quetiapine (Seroquel®, AstraZeneca, London, UK) – Limited available information suggests that quetiapine reduces symptoms with relatively few side effects, the most common being sedation and weight gain. There was no evidence of EPS.
· ziprasidone (Geodon®, Pfizer Inc., NY, USA) – No published reports of use in children with schizophrenia. Use in adults appears effective with no significant weight gain. However, ziprasidone is linked with a lengthening of cardiac output rhythms (heart beat) and so may not be safe for children.
· aripiprazole (Abilify®, Bristol-Myers Squibb, NY, USA) – Newest antipsychotic released. There are no published reports of use in children. Data in adults suggests a low frequency of common side effects such as weight gain and movement disorders.

Overall, much research needs to be done to determine which antipsychotics are the safest and most effective for children and adolescents. Given the current limited data, the authors of this paper suggest that treatment of children with schizophrenia begins with risperidone, olanzapine, or quetiapine. They also recommend that medication dosage begins low and increases slowly, as side effects appear to increase with rapidly increasing, or high final doses. As is true for any brain disorder concurrent psychosocial therapy is highly recommended. For children using antipsychotics this may include dietary education for patients and family in order to combat weight gain, as well as continual monitoring for movement disorders and developing medical conditions, such as cardiovascular disease. Ongoing research and the development of new antipsychotic agents hold future promise for both young and old suffering from schizophrenia.